Articles tagged with: new RAH

What is focal therapy of the prostate?

In some ways, prostate cancer treatment has fallen behind other cancers. Although robotic surgery is a less invasive way of removing the prostate than an open cut, we are still not at the stage of being able to target cancer cells or groups of cells, and leave behind other non-cancerous cells in the prostate. This focused, or focal, treatment could have advantages in that important nearby structures are less at risk of damage compared to an operation to remove the prostate.

One of the issues is that, for some men, prostate cancer can be a multi-focal disease, meaning that it can occur in multiple areas of the prostate. Others may just have one 'index' lesion that needs treating, and these people could be good candidates for focal treatment.

High quality imaging is key

The key is high quality imaging of the prostate. There have been steps in the right direction with the use of multiparametric MRI of the prostate- see
here and
here.

A well performed mpMRI read by an expert radiologist is a powerful tool in identifying areas of the prostate that need biopsy - see
here and
here.

Accurate biopsy is very important

If we can have accurate biopsy - see
here - and be confident that this is a true representation of the degree of prostate cancer present, then it is just a small step to say that we could apply treatment to a focused area of the prostate to reduce the side effects of treatment for some men. Ask your urologist if he or she offers software fusion biopsy of the prostate.

Potential avenues for focal prostate cancer treatment

Currently, there are various options for development of focal therapy:

1 - focal brachytherapy - see
here for more information about brachytherapy - which is essentially just brachytherapy applied to one side of the prostate

2 - High intensity focused ultrasound (HIFU) treatment. This has been used in the past to treat the whole prostate, and results were mixed. Although focal-HIFU is in theory a slightly different approach, a lot of work needs to be done before this could be an accepted treatment

3 - Focal laser ablation using photodynamic treatment. Here a compound is injected, which is taken up by abnormal cells in the prostate. A laser is fired that is specific for the compound, and the laser causes a reaction in the compound that kills the targeted cells. The idea is that normal cells are not affected

4 - Direct laser energy targeting of the abnormal area in the prostate. This is the simplest, most direct and elegant idea - the area that is known to be abnormal and cancerous (from the MRI and subsequent biopsy) is targeted directly by a laser fibre. This approach has been investigated and used by urologists at UCLA in the States, and may hold out promise for the future

Conclusion

As surgical treatments become more refined, we hope that an increasing number of patients will be offered focal treatments. It is important that your urologist is able to discuss and offer a range of treatment. Most important is that the treatment is the right one for you.

Low dose rate (seed) brachytherapy for prostate cancer in men under 60 years

What did the study show?

Langley et al. reported (Jan 2018) on the outcomes of men treated with seed implant (LDR) brachytherapy. The study suggests that low-dose-rate brachytherapy is a very effective treatment, with excellent long-term control of prostate cancer in men aged ≤ 60 years at time of treatment.

597 patients with a median age of 57 (range 44-60) years were followed
up for a median of 8.9 years (1.5- 17.2 years range of follow up). The 10-year
relapse-free survival rates (this means the percentage of men who, at 10 years, have no evidence of recurrent cancer) using the Phoenix definition for biochemical failure were as follows:

95% for low risk prostate cancer

90% for intermediate risk prostate cancer

87% for high-risk prostate cancer

Of the 597 men, only six (1%) died from prostate cancer during follow-up.

Erectile function was preserved in 75% of men who were potent before treatment.

Important points to highlight from the study?

1. These results are excellent. It is interesting to note that in Australia, LDR brachytherapy probably would not be used for high risk prostate cancer.

2. The follow up period is reasonably long, but prostate cancer has a long natural history, which means that it can take many years for it to declare itself if it is going to come back, and therefore it takes a long time to know if treatment has been effective.

3. The median follow-up was 8.9 years, but the calculation of biochemical recurrence (a sign of prostate cancer coming back by a continued rise in PSA) was worked-out from a median follow-up of 5.9 years. As we know with many other studies in cancer, the longer the follow up period, the more men may develop recurrent prostate cancer. This is true of any form of treatment, whether it be radical prostatectomy, radiation or brachytherapy.

4.The rate of prostate cancer mortality is very encouraging, but again, follow-up was relatively short, and recurrences and deaths can occur in the period 10-15 years after treatment.

5. Experience is important in prostate brachytherapy. This study reported excellent dosing of the prostate (how much radiation was delivered to the prostate). This can be measured by something called the D90, which indicates the quality of the seed implant. In this study, these values were excellent. In Adelaide, these figures are very carefully assessed by an expert team of radiation physicists after any seed implant.

6. Because this was not a randomised study, one cannot make any direct comparisons
between surgery and brachytherapy, and this is an important discussion for any prostate cancer patient. It is ideal if you can discuss your treatment options with someone who is able to offer you both treatments, or at least work in a practice where both treatments are available. This is likely to reduce any bias in advice given to you.

Summary

These are excellent outcomes for both cancer control and preservation of erectile function. LDR brachytherapy is a very good treatment option for younger (or older) men with prostate cancer. The decision about your treatment needs to be discussed in detail with a urologist who can offer both options for treatment.

Focal laser therapy may offer new options for men with prostate cancer

The idea of focal ablation (localised ‘killing off’) of cancers is not new – surgery for breast cancer was revolutionised years ago by the development of lumpectomy or wide local excision of tumours of the breast, rather than mastectomy (removal of the entire organ), in some settings. This idea has been slow to gain traction in prostate cancer, but may be a sensible option for tumours in the near future.

There are various options for focal ablation, and MRI-guided laser ablation shows a lot of promise in low and intermediate risk prostate cancer. Here, the very accurate application of heat energy from a laser is used to destroy prostate tumours. The position of the laser fibre in the prostate is guided by magnetic resonance imaging (MRI) and ultrasound using a fusion system. This is possible under sedation and local anaesthetic, as shown by a group at UCLA in the States. They first reported their findings in the Journal of Urology back in July 2016 (see here), and they followed up the study with a presentation at the American Urological Association Annual meeting in May 2017 (see here).

Importantly, their study found no serious adverse effects on erections or ability to control urine in their first 18 patients. It is possible that this treatment could be a further option for patients with prostate cancer, improving outcomes by reducing side effects.

One of the concerns often expressed is that focal therapy doesn’t remove the whole prostate and therefore new prostate cancers can grow. Certainly, in some people, prostate cancer is a multifocal disease, meaning there is more than one focus in the prostate and that remaining areas of the prostate could develop cancer. However, this is not true for all patients or all cancers, and in some patients, removal of the entire prostate, with its potential associated problems, is too aggressive. Careful selection of treatment to suit the patient is the important issue, particularly now we have much more accurate ways to visualise the prostate and cancers with multiparametric MRI.

Similar Biobot system used at nRAH

A similar system for biopsy (the ‘Biobot’), using MRI and ultrasound fusion has been used for over 15 months at the Royal Adelaide Hospital
(see here).

The next stage in development of the Biobot is a software add-on for the delivery of focal therapy. The system used by the authors of the study was the Artemis, which is similar.

Importantly, the authors of the study felt that they had developed the expertise for focal therapy through the use of MRI fusion biopsy, and that this was excellent experience that allowed them to go on to develop this focal treatment. This form of treatment is not yet available in Australia.

Nick Brook will be in Belgium from April to Sept 2018

I will be undertaking a period of advanced robotic surgical training at Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium from April to September 2018, under the mentorship of Prof Alex Mottrie.

The OLV is a high-volume robotic surgery hospital with a large department of Urology. The hospital has been undertaking robotic surgery since 2001 and is closely aligned to the OLV Vattikuti Robotic Surgery Institute (ORSI). The urology department produces a large volume of clinical data on outcomes for robotic surgery and regularly reports on new techniques.

Advanced robotic skills to bring back to Adelaide

The aim of this outstanding and internationally recognised fellowship is to gain full competence in a range of advanced urological robotic-assisted techniques. The training is purely in robotic urology – five days of operating a week. I will return to Adelaide and be able to provide these advanced techniques to patients. The training serves three purposes. First, after six-months I will be fully trained in a range of urological robotic surgery. I will be able to bring these skills back to South Australia for service provision from October 2018. Second, the time will be invaluable in developing the skill set necessary to train our local urology registrars in robotic surgery. Since robotic surgery was introduced in SA in 2004, no registrars have been able to train in robotic surgery. It is vitally important for South Australian patients that doctors of the future are able to provide this kind of surgery. Third, the academic work and clinical outcomes data will open-up the possibility of international collaboration in this area for South Australia.

I undertook a period of fellowship training (2008-2009) with Prof David Nicol in Brisbane, and was appointed as a consultant Urologist in Adelaide in 2009, where I have been a urological surgeon with broad practice including benign and cancer work. I have a particular interest in urological cancer surgery and have been instrumental in developing urology cancer provision at the Royal Adelaide Hospital into a fully functioning multidisciplinary service. I have made a large contribution to the public service system by bringing innovative strategies and significant funding to the department.

I see a great number of benefits to this 6 month fellowship for the provision of service to the public and private hospital systems in Adelaide, and also for the development of our training registrars. I will be unpaid for this period, and will be leaving a young family in Adelaide for six-months. I believe this demonstrates my dedication to further training and professional development, and its importance for bringing high level robotic urology surgery skills to South Australia.

Robotic prostate biopsy

In January 2017, Nick Brook organised for a 6 month free trial of the Biobot robotic biopsy system at the Royal Adelaide Hospital. This is the first such system in South Australia, and was only the third in use in Australia.

The system uses a patient's MRI scan and fuses this with a real-time ultrasound of the prostate to enable targeting of suspicious areas in the prostate.

Increased accuracy of diagnosis leads to increased confidence that the correct treatment can be chosen.

Software controls the robotic arm, to ensure that the needles are placed in the correct position for biopsy

The Advertiser story on the introduction of the Biobot to South Australia by Nick Brook can be found here